Thesis--Wisconsin. / Includes bibliographical references (leaves 70-73).

Thesis (M.Nurs.)--Washington State University, December 2006. / Includes bibliographical references (p. 30-33).

Thesis (M.P.H.)--University of Hong Kong, 2005.

Thesis (M.M.) Florida State University, 2005. / Advisor: Jayne M. Standley, Florida State University, College of Music. Title and description from dissertation home page (viewed 6-25-07). Document formatted into pages; contains 49 pages. Includes biographical sketch. Includes bibliographical references.

Childbirth holds short and long-term physical and psychological effects for women. Yet, numerous investigations into childbirth have overlooked the delicate interrelated psychological and emotional interplay that women experience, in favour of the physical, such as the outcomes of birth, maternal mortality, and the physical skills of healthcare providers. Although quantitative measures derived from these are important to establish and evaluate maternal health, they are not adequate to explain the complexity of the human experience of childbirth. Without this understanding there is inadequate guidance about how to proceed to achieve the Sustainable Development Goals targeting maternal health. The aim of this study was to explore childbirth experiences of women giving birth in Zambia, in order to better understand how they experience and give meaning to the phenomenon. The study was guided by an interpretive phenomenology approach. This type of phenomenology was found to be appropriate because the study sought to understand childbirth within the context of everyday lives of women birthing in Zambia. Purposive sampling was utilised to recruit 50 women aged between 16 and 38 years. The women had birthing experiences that occurred between 2005 and 2011. The birthing experiences were from all the ten provinces of Zambia. Data were collected through in-depth unstructured interviews, which were tape recorded. Data analysis was guided by van Manen’s six steps of analysis. Seven themes namely: 1) Conforming to societal norms, 2) Clash between traditional and contemporary childbirth practices, 3) Being in a dilemma, 4) Loss of dignity, 5) Feeling insecure, 6) Inadequate service provision, and 7) Being there for the woman, emerged from the analysis. Each theme had several sub-themes that provided a clearer picture of how participants experienced the phenomenon. The embodied experiences of participants illuminated the complex context of childbirth, whereby, the phenomenon was experienced in private, behind the closed door of secrecy that encompassed difficulties and issues such as, lack of choice, sub-standard care, discrimination, fear and conflicting information. The findings revealed that there was a need for an attitudinal change in maternity care professionals towards a more caring approach, as well as a parallel need to build agency and autonomy in women. For women, the change needs to be addressed at an individual and societal level, beginning with simple things, such as assertiveness training through to educational opportunities, so that they develop economic independence. Macro-reforms (top-down change) need to be combined with micro-reforms (bottom-up change) to challenge existing discriminatory, oppressive and patriarchal attitudes and practices that impact on women’s birth experiences. Women’s voices need to be heard. Understanding maternal outcomes at a micro level can help inform decisions and influence policy at the larger macro levels of institutions and government. Overlooking this intrinsic level represented an important barrier to utilisation of skilled birth care and constituted a common cause of suffering and human rights violations for birthing women. The key implications for practice pointed to a need for all maternity care stakeholders in Zambia to have an understanding of how women birthing in Zambia experience and give meaning to the childbirth phenomenon. This could start by re-examining current approaches to improving reproductive health, and addressing the contextual factors and community based issues that have been brought to light in this study. In the absence of such an understanding it is difficult to map out interventions that do not infringe on women’s beliefs and practices.

Background: GDM is a state of glucose intolerance first diagnosed in pregnancy. It is a pre-diabetes state, predisposing both the mother and offspring to future risk of diabetes. GDM is associated with increased risk to macrosomia, adiposity, Caesarean Section (CS) delivery, shoulder dystocia, and neonatal hypoglycaemia. SA have a greater than two fold risk of both GDM and future diabetes risk compared to WC. However, despite having higher levels of hyperglycaemia in pregnancy, SA babies are amongst the smallest babies in the world. The mechanism behind this increased glycaemic risk in SA is complex, multifactorial and unclear. Disordered hypothalamic-pituitary-adrenal axis (HPA) has been linked to adult diabetes, obesity and metabolic syndrome in WC but has not been studied in SA. The current management of GDM is largely based on evidence from studies in WC and has been extrapolated to other ethnic groups such as SA. This includes: diagnostic criteria to define GDM, postnatal screening methods for postpartum glucose abnormalities, effect of GDM on offspring birth weight (BW) and fetal growth in GDM. Through this research we aim to explore the ethnic differences between SA and WC in the applicability of diagnostic criteria, post partum screening methods, effect of GDM on BW, fetal growth patterns in GDM and also examine ethnic differences in HPA activity as a potential mechanism underlying the increased glycaemic risk in SA in pregnancy. Methods: i. Retrospective analysis of a routinely collected multicentre data (n=14477) over a 3-year period was used to study the applicability of various GDM diagnostic criteria and post partum screening methods. A subgroup analysis of the above data set was used to compare fetal growth between SA and WC (177 WC and 160 SA). ii. A retrospective analysis of a large birth weight cohort (n=53,128) from Leicestershire between 1994 and 2006 was used to compare the effect of maternal diabetes and GDM on BW in SA and WC. iii. To examine fetal growth in SA, a retrospective case control analysis of serial fetal biometry was performed between GDM and control population from India. (178 controls and 153 GDM) iv. To explore underlying HPA dysfunction as a potential mechanism for increased glycemia in SA and ethnic differences in HPA behaviour a prospective cohort study comprising of high risk pregnant SA and WC women was performed. Diurnal salivary and urinary cortisol excretion was studied in relation to glycaemia in SA and WC (n=100, 50 SA, 50WC) Results: i. The newer IADPSG detects obese women with mild fasting hyperglycaemia. The benefits of treatment of hyperglycemia are not well established. The increase in detection rates of GDM with the new NICE and IADPSG criteria were uniform across ethnic groups in a selectively screened population. ii. Postnatal screening with oral glucose tolerance test (OGTT) is associated with poor uptake in all ethnic groups, which improves substantially with using HbA1c. SA were more likely to attend postnatal screening with HbA1c compared to WC. Screening for postnatal diabetes using FPG is more likely to miss women of non-WC ethnicity owing to the larger proportion of post-load glucose abnormalities. iii. The BW increase associated with maternal diabetes was lower in SA by 139g compared to WC. iv. Important ethnic differences in fetal growth were noted. SA fetuses had overall smaller measures of head and abdomen circumferences, but with disproportionately smaller abdominal circumference compared to WC, signifying early evidence of a head sparing growth restricted pattern. v. SA fetuses of GDM mothers showed early evidence of increased abdominal adiposity at 20 weeks with smaller measures of other fat free mass and skeletal growth compared to non-GDM controls vi. SA had higher cortisol awakening responses compared to WC. First trimester waking cortisol was an independent predictor of glycaemia in the third trimester. Despite significantly lower BMI, SA had similar glucocorticoid (GC) excretion to WC. Urinary GC excretion was independently predicted by maternal adiposity and not BMI in SA. Conclusion: This research addresses important gaps in the literature in gestational diabetes in SA. There are important ethnic differences in the impact of maternal diabetes and gestational diabetes on BW and fetal growth, and evidence of early increase in adiposity at the expense of lean body mass in SA. This research provides novel evidence to support the argument for ethnicity tailored management of GDM. Our research also provides novel evidence for disordered HPA activity as a possible mechanism for the increased glycemic risk in SA. Larger randomized prospective studies incorporating offspring outcomes in relation to HPA are needed.

Waterbirth practice has the potential to support a midwifery model of care and yet little is known about how the organisation of care can be changed to improve the use of birthing pools. This action research study focused on a group of midwives working on a labour ward in an English obstetric led maternity unit with 3,800 births and 25 recorded waterbirths per year. Interviews and focus groups with labour ward midwives and managers were employed to identify barriers to birthing pool use and inform the change process. Three problem-solving workshops with labour ward coordinators were organised with the aim of influencing other midwives’ use of birthing pools. Data from a newly developed waterbirth questionnaire and maternity records were used to evaluate change in levels of personal knowledge, waterbirth self-efficacy and social support. Foucauldian discourse analysis and One-Way ANOVA with Tukey post hoc tests were used to analyse qualitative and quantitative data. Fourteen midwives took part in focus groups and seventeen in interviews over four research phases. Interventions, developed by workshop attendees, included improvements to the recording and dissemination of waterbirth and water immersion data, target setting and the appointment of a waterbirth champion. By the end of the study the numbers of waterbirth practitioners, recorded waterbirths and social support increased significantly. Discourse analysis revealed the presence of dominant biomedical and subjugated ‘being with woman’ midwifery discourses. The study is the first to describe midwives’ attitudes to waterbirth practice and attempt to improve the use of hospital birthing pools. The findings illustrate that, by co-opting rather than replacing dominant discourses, it is possible to support the delivery of a midwifery model of care in a medicalised environment. As such this study offers a pragmatic approach to organisational change.

Background: Slow progress of labour (SPL) occurs in 3-37% of all labours. It constitutes the main cause of primary caesarean section (CS) and is associated with operative births, maternal and foetal morbidity, and a negative birthing experience. SPL is also the principal reason for the transfers of women from midwife-led units (MLUs) or their home, to hospitals. The current standard medical management of SPL, including intravenous administration of synthetic oxytocin and artificial rupture of membranes (ARM), has been increasingly questioned and the need for alternatives recommended. A midwifery approach to SPL represents a possible important alternative. However, contemporary literature shows a surprising dearth of research concerning midwives’ approaches to SPL. Birth centres appear ideal settings for exploring a midwifery approach to SPL, given the strong midwifery philosophy and the relevance of SPL reported in these contexts. Aim: To explore midwives’ approaches to SPL in birth centres, focusing in particular on midwives’ understanding of the phenomenon, diagnostic process, clinical management and decision-making. Methods: A qualitative multiple case study, underpinned by a critical realist perspective. Midwives’ approaches to SPL represented the ‘case’ of interest; an Italian alongside- (AMU) and an English freestanding- (FMU) midwifery units were purposively selected as case-sites. Data was collected between November 2012 and July 2013, after obtaining all necessary ethical approvals. An inductive reasoning, and triangulation logic characterised data collection. Multiple methods were adopted including individual semi-structured interviews, focus groups, observations and document reviews. Practising midwives, midwife managers and two lead obstetricians were included as participants after obtaining written informed consent. Data was analysed at two levels, within-case and cross-case, using a thematic analysis. Findings from the cross-case analysis supported the development of assertions and final conceptualisation regarding midwives’ approaches to SPL in birth centres. Findings: At the Italian site, midwives identified SPL as the problem of their care in the AMU. They perceived the process of recognition of this phenomenon as an engaging challenge and attempted to untangle the main cause amongst the many intertwined ones, in order to tailor their approach. Dealing with SPL represented a struggle; midwives adopted several different interventions and their decisions appeared enabled or constrained by numerous factors, especially the problematic relationship with the hospital staff. At the English site, SPL was not considered an issue, midwives were keen in looking at diagnostic and causal factors of SPL within a bigger picture. Midwives’ interventions aimed at giving women the best chance to overcome SPL and give birth in the FMU. The several influential factors were managed by many midwives through experience. Across cases, midwives’ understanding of SPL varied. SPL was acknowledged to result from a complex interaction of causes. Early labour was considered a critical stage for the development of SPL. The process of recognition of SPL appeared a dynamic one and aimed at reaching an objective diagnosis. Distinguishing whether SPL represented a physiological rest or arrest of labour progress represented an emerging dilemma. Midwives tailored interventions to single situations. Some interventions appeared to be fundamental to midwifery care, whilst others depended on various factors. Midwives’ relationships with all factors in the context appeared to be pivotal for both performing interventions and decision-making. Conclusion: This is the first case study exploring midwives’ approaches to SPL in birth centres, in both an English and an Italian context. This research outlines midwives’ approaches to SPL as a result of a complex and dynamic system. Midwives’ understanding, identification, clinical management of SPL and decision-making represents a multifaceted and stratified reality. The individual characteristics of the women, the birth attendants, the midwife, and colleagues, as well as the relationships occurring in this context, represent the main factors whose variable interactions may result in variable manifestations of the midwifery approach. On the basis of the findings of this research, recommendations are made for midwifery practice, education and research.

Polycystic Ovary Syndrome (PCOS) is a complex disorder encompassing reproductive and metabolic dysfunction. Ovarian hyperandrogenism is an endocrine hallmark of human PCOS. In animal models, PCOS-like abnormalities can be recreated by in utero over-exposure to androgenic steroid hormones. This thesis investigated pancreatic and adrenal development and function in a unique model of PCOS. Fetal sheep were directly exposed (day 62 and day 82 of gestation) to steroidal excesses - androgen excess (testosterone propionate - TP), estrogen excess (diethylstilbestrol - DES) or glucocorticoid excess (dexamethasone - DEX). At d90 gestation there was elevated expression of genes involved in β- cell development and function: PDX-1 (P < 0.001), and INS (P < 0.05), INSR (P < 0.05) driven by androgenic excess only in the female fetal pancreas. β- cell numbers (P < 0.001) and in vitro insulin secretion (P < 0.05) were also elevated in androgen exposed female fetuses. There was a significant increase in insulin secreting β-cell numbers (P < 0.001) and in vivo insulin secretion (glucose stimulated) (P < 0.01) in adult female offspring, specifically associated with prenatal androgen excess. At d90 gestation, female fetal adrenal gene expression was perturbed by fetal estrogenic exposure. Male fetal adrenal gene expression was altered more dramatically by fetal glucocorticoid exposure. In female adult offspring from androgen exposed pregnancies there was increased adrenal steroidogenic gene expression and in vivo testosterone secretion (P < 0.01). This highlights that the adrenal glands may contribute towards excess androgen secretion in PCOS, but such effects might be secondary to other metabolic alterations driven by prenatal androgen exposure, such as excess insulin secretion. Thus there may be dialogue between the pancreas and adrenal gland, programmed during early life, with implications for adult health Given both hyperinsulinaemia and hyperandrogenism are common features in PCOS, we suggest that their origins may be at least partially due to altered fetal steroidal environments, specifically excess androgenic stimulation.

Partnership working has become something of a government imperative for tackling complex public health issues and is now more often the norm than the exception in health education and disease prevention work. The literature however, highlights that partnership working may be explained more by rhetorical appeal rather than any concrete evidence of effectiveness. There is little evidence from the literature examining the functioning, effectiveness or outcomes of partnership for health improvement. Partnership working was used within one such public health initiative (Healthy Respect) as a means of implementing and delivering a complex sexual health intervention programme to young people aged 10-18 years in Lothian. The main aim of Healthy Respect was to create an environment that would lead to long term improvements in the sexual health and wellbeing of young people through a multi-faceted approach which linked to education, information and services. This PhD study aimed to assess the extent and impact of partnership working in the Healthy Respect project; it aimed to examine the process and outcomes of partnership working for the organisations involved in the programme and to theoretically assess how this may impact on improving young people’s sexual health and wellbeing. The study used Healthy Respect’s logic model as a framework to examine the theory of how change occurred through partnership working in the project. A mixed method research design was used consisting of two postal surveys and in depth interviews with a sample of providers delivering sexual health education, information and services to young people in Lothian. Results suggest that Healthy Respect was only partially successful in working in partnership with some of the organisations involved in delivering sexual health education, information and services to young people. Partnerships were formed with approximately half of the providers. Those most engaged and working in partnership with Healthy Respect were from the NHS (including school nurses) and voluntary organisations which offered sexual health services to young people. Sexual health services also occupied a dominant position in the local networks of providers. Many providers linked with these services including secondary schools which offered Sexual Health and Relationship Education (SHARE). Other organisations most notably those from the Local Authority organisations were less willing to work in partnership with Healthy Respect. Many of the barriers (identified through the qualitative interviews with providers) to working in partnership with Healthy Respect came mostly from the Local Authority organisations and offered an explanation as to why partnerships with these organisations didn’t develop as planned. Results did suggest that where partnership work was taking place, this impacted on an organisations ability to deliver sexual health information, education and services to young people. However, partnerships with Healthy Respect were only formed with approximately 46% of the providers targeted, therefore not all organisations and subsequently young people would have benefitted from the Healthy Respect programme. The Healthy Respect programme was heavily reliant on partnership working to deliver the complex intervention. Yet results suggest that they were only partially effective in working in partnership with the organisations involved which may have led to them having little impact on the sexual health and wellbeing of young people (especially the most vulnerable). Partnerships take a long time to build and require a great deal of time and resources to be invested in them to work. However, the results of the study leave us with the fundamental question of whether all this time and effort should be applied to partnership working and interventions of this type for what could be very little impact on young people’s sexual health? This study has contributed to knowledge in the area of partnership working for health improvement. It defined what partnership was using a range of methods which moved beyond supportive attitudes and was able to examine and measure both the process and outcomes of partnership work in this project, something which few studies have been able to achieve.